The medical industry has been battling key issues for years. The difference now is that the pandemic has prompted inflation, increased shortages, more complex technology, and the largest disenrollment in health coverage in years. Not to mention one of the largest increases in mental health demands ever seen. Before we discuss the challenges, let’s review the role of the CNO.

What is a CNO?

The CNO is the top-level, non-clinical administrative head of all nursing services of hospitals, agencies, and health care systems. Most commonly, they are individuals with advanced degrees, such as a Ph.D. or a Master’s degree. They are considered at the top of the nursing pyramid and some general responsibilities are:

• budgeting
• staffing
• developing and implementing organizational goals and standards of care
• planning new patient services
• ensuring compliance with all laws and regulations
• empower nursing staff to provide the best patient care

While the CNO has many responsibilities, there will always be some concerns that have top priority. With the recent changes in healthcare, these are 5 of the top topics for 2023:

1. Retention and Recruitment

The problem

Widespread burnout and turnover after Covid have led to professional disengagement in staff, and severe nurse staffing shortages. Fewer veteran nurses are available to teach and mentor new graduates, as many of the experienced nurses left the profession, or turned to travel nursing for pay incentives. (Pay rates for travel nurses have increased from $1,894 (Jan 2020) to $3,173 (Dec 2022) per week). High turnover leads to soaring costs for the organization. This leads to:

• lower customer satisfaction scores
• lower patient safety
• increased mortality rates

High leadership turnover also has consequences and often results in an unstable culture, decreased morale, professional disengagement, and a toxic work environment. The C suite is currently operating at approximately 20% turnover and executives are reporting feeling emotionally exhausted, feeling significantly less productive than before Covid, and considering career changes.

The solution

CNOs need to be more aggressive about workforce planning and have a multi-faceted approach. Nurses are demanding better work-life balance, and organizations need to become more competitive. Location and higher salaries also help w recruitment and longevity.

• Incentives for seasoned nurses. Shorter shifts, better pay, and schedule preference.
• Proactive approach to succession planning
  • Training programs to promote nurse growth and resilience.
  • Retention strategies to increase the 2-year average of millennial and Gen Z nurses.
  • Invest capital for internal recruitment.
  • Strategies to combat nurse burnout.
  • Offer care models to allow nurses to practice at the top of their licenses, and innovative ways to provide quality care. (This increases retention and promotion within the organization).
• International nursing programs
• Build Newly Licensed Registered Nurse programs (NLRN)
• In-house nursing programs:
  • allows nurses to travel within their organization
  • increases flexibility in the schedule
  • reduces the need for external contract nurses
• Academic partnerships
• Tuition reimbursement
• Housing assistance
• Student loan assistance
• Provide experienced nurses (if there is a skill gap) by using staffing agencies.

Funds must be allocated to where they can make the largest impact. Nurse retention, succession planning, and recruitment all lead to better overall outcomes for both staff and patients.  Decreasing turnover saves money in training and orientation and having experienced nurses on your healthcare teams increases safety and satisfaction scores.

2. Declining Reimbursements/CMS Disenrollment Spring of 2023

The problem

When the Public Health Emergency (PHE) was declared by the federal government during Covid-19, some regulatory actions and waivers allowed for changes in healthcare. This was to help streamline delivery and increase patient access to care. Some of these were permanent changes while others are set to expire on May 11, 2023. Centers for Medicare and Medicaid Services (CMS) will be reviewing customers and performing the largest disenrollment in years. Millions of Americans may lose their Medicaid coverage because waivers and temporary PHE laws did not allow the group to deny services.

• This may leave a large portion of customers with no coverage which will hit payers, due to a drop in paying customers.
• Scope of practice changes during the PHE allowed certified nurse anesthetists (CRNA) to practice without direct supervision of a physician, instead of under the discretion of the hospital or Ambulatory Surgical Center (ASC). This is scheduled to end on May 11, 2023.
• Some Telehealth waivers will end.
  • Telehealth has increased more than 30-fold since the beginning of the declaration of the PHE. Individuals with Medicare had broad access to health via telephone or computer, without any location limits. As these waivers end, limits and conditions will return and CMS may struggle to maintain the current access to care.
  • CMS encourages states to continue coverage of telehealth, but it will be limited services, determined by the individual states.
  • Many rural areas that have minimal or no local resources will be negatively impacted by the inability to access telehealth or virtual doctor visits.
  • Loss of telehealth may lead to increased ER visits, urgent care visits, and more strain on local physicians.
• Waivers for health aids to be trained and certified within 4 months of hire have ended. This potentially can lead to hospitals being short-staffed with certified caregiver aids.
• Blanket waivers for hospitals in response to emergencies will end. These can include things such as limitations on lengths of stay, the number of admissions in a critical area, and the ability for acute care patients to be housed off-site. (Examples; ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories.)

The solution

Disenrollments in CMS will most probably happen continuously for the remainder of 2023. Healthcare facilities will need to review changes, determine eligibility for programs, and apply for waivers if appropriate.

• Under the Consolidated Appropriations Act of 2023, the Acute Care at Home program has been extended. This gives hospitals until the end of 2023 to continue these services which could temporarily free up healthcare personnel.  
• Training and certification need to be completed for staff that will not meet the new guidelines.
• Review of staffing to ensure laws of the scope of practice are met and hiring or reorganization of personnel may be required.  
• Application of waiver extension for Scope of Practice is possible on a state-to-state basis. This will depend on the best interest of the patient, so a review of these will be critical.
• Organizational analysis will need to be conducted to review all changes in CME to ensure facility compliance.

3. Artificial Intelligence and Digital Transformation

The problem

In recent years Artificial Intelligence (AI) and Machine Learning (ML) have made massive progress in the healthcare industry, and this year ML is expected to top $20 million in sales. Digital transformation is fundamental in healthcare, and experts believe that 70% of healthcare organizations will rely on these strategies by 2027. Finance, technology, robotic process automation, and analytic strategies are all gaining traction, but usage is not currently being optimized.  These programs will reduce manual labor, increase efficiency, and improve healthcare by predicting health trajectories, recommending treatments, and automating administrative tasks.

Healthcare organizations will need to perform as platform-based business modules instead of growing point solutions. A survey of top decision-makers in health systems found that 60% of these organizations use over 50 software solutions, and a quarter of them have as many as 150. System integration, as well as application programming interfaces (API), will soon become the standard with API funds expected to triple by 2030.

The solution

There are many different AI-aligned technologies, and organizations will need to implement these or fall behind their competitors. Healthcare organizations must create positions such as Chief Digital Officer and Chief Transformation Officer. These positions will focus on initiatives at the department level, and devise user incentives to aid with hospital-wide implementation.

Some of the most common applications for the use of AI in healthcare organizations are:  

• Utilizing Natural Language Processing (NLP) to create, understand, and classify clinical documentation and published research.  This can analyze clinical notes on patients, prepare reports, and transcribe patient visits.
• Delivering more personalized healthcare by sorting through massive amounts of data to individualize treatment plans, track progress, diagnose with higher efficiency, and provide better outcomes.
• Drug discovery will assist in predicting outcomes, side effects, and efficacy.
• Analysis of medical imagery will be used to predict new diseases.
  • In Budapest, Dr. Eva Ambrozay uses AI to detect breast cancers on mammograms that previous imaging would have missed.
• Robotic process automation in healthcare to reduce repetitive tasks such as prior authorizations, billing, and updating patient records.
• Decreasing the cost of healthcare by automating many tasks that are time intensive.
• Quickly identifies patterns in large amounts of medical information to improve medical research for new therapies and treatments.
• Using chromosomal information to understand different genetic variants of cancers and their responses to drugs and treatments.

4. Cybersecurity

The problem

Cyber security and patient privacy are one of the biggest concerns of most healthcare organizations, and there will be more pressure than ever to invest in better technology to prevent cyberattacks. Just in the last few years, there has been an increase in both the number of attacks and their severity. During the pandemic, we saw increased telehealth and remote work which heightened vulnerabilities. With the expanded use of AI, large quantities of data are available to more people and organizations, and with that comes increased risk.

The solution

 HIPPA-covered entities and business associates must mitigate risks and run organization-wide preparedness drills. These cyber-threats include more than just electronic health records.

• Run a comprehensive risk analysis.
• Maintain offline encrypted backups and test these regularly.  
• Conduct regular scans to identify vulnerabilities.
• Conduct regular patches and updates of software and Operating Systems.
• Train employees on the types of IT attacks and contingency plans.
• Use segmentation (the dividing of networks into smaller sections) to further reduce the accessibility of an attack.  
• Have a plan in place if your organization suffers from a cyber security attack, including multiple organizational teams. (IT, legal, communications, pharmacy, and so on)  
• Look at alternative program storage, like Apple or Google. Storage space for purchase often has higher security and already has built-in codes rather than creating your own, which can save money.

5. Behavioral Health/Mental Health Challenges

The problem

Mental disorders are the leading cause of disability worldwide. Overcoming barriers to mental health care continues to be a major issue. Approximately 1 in 5 Americans over 18 years of age live with a mental illness. In 2020 data shows us that there were 45,979 suicides and that number increased to 47,646 in 2021. With limited accessibility, financial barriers, and stigmas, many patients go untreated. Consequently, Emergency Departments are often flooded with mental health emergencies, such as severe self-neglect, self-harm, depressive or manic episodes, anxiety, substance abuse, or withdrawals.  Outside of emergency medicine, patients face other challenges, such as health inequities, lack of access or healthcare insurance, and financial challenges.  

The solution

Political support and policy change are the most effective ways to change healthcare and people’s access to it. While that may be out of our hands, there are other ways to help meet the needs of our hospital patients.  

• EDs should have at least one designated seclusion room. These offer a safe place for the patient in crisis and protect staff and other patients/visitors.
  • Must have both video and audio monitoring for constant supervision.
  • Safe place for patients that are on suicide watch, or those who are at risk of harm to themselves or others.
• Adequate mental health staffing is important. A counselor or mental health professional should be either on-site or on-call 24 hours a day.
• Emergency plans are available for a mental health crisis. Ongoing training and education should be provided for emergency staff in identifying assessing and managing patients that present with mental illness or potential suicide.
• A designated mental health area should be available to non-emergent patients, even temporarily, until admission or referral is completed.
• If admission is not justified, a short-term management plan should be in place until the follow-up or referral can be coordinated.
• Mental health services should be readily available for hospital staff.
  • Many nurses and others in the healthcare profession are experiencing personal mental health concerns- especially since the Covid -19 pandemic. Increased resources can help reduce burnout, stress, and anxiety and ultimately staff turnover and retention.

Summary

CNOs and other hospital personnel have a large responsibility to both their organization and to the public. Due to recent changes in healthcare, 5 of the top topics in 2023 are:  

• Retention and Recruitment. This encompasses staffing shortages, temporary labor, staffing budget issues, succession planning, and leader turnover.
• Declining reimbursements from Centers for Medicare and Medicaid Services. This includes the elimination of certain waivers and disenrollment due to the end of the public health emergency.
• Artificial Intelligence and Digital Transformation. AI has recently picked up traction in the medical field, and changes are being made quickly. Hospital organizations need to keep up with technology and implement platform-based business modules. This will result in the best patient care and patient outcomes, and limit the cost of health care.
• Cyber attacks. Recently there has been an increase in both the number of attacks and their severity. With more people working from home and increased use of telehealth, this will continue to be an evolving concern.
• Behavioral Health/Mental Health Challenges. In the U.S., 1 in 5 suffer from mental health issues. These affect our providers and patients alike. Support systems need to be in place, adequate staffing available to ensure safety, and local resources need to be accessible.   

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CMS Finalizes Changes for Telehealth Services for 2023 | Foley & Lardner LLP

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Digital Transformation Among Leading 2023 Trends | HealthLeaders Media

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6616181/

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